Cardiovascular Medicine

Physicians in the Aortic Disease Center at Brigham and Women’s Hospital (BWH) offer comprehensive, multidisciplinary care for patients with aortic conditions, including aneurysmal disease, aortic dissection, and traumatic rupture. R. Morton Bolman, MD, BWH Chief of Cardiac Surgery, says, “At the Aortic Disease Center we offer a disease management paradigm. We will provide expert, appropriate, and timely care – diagnosis, surveillance, treatment, and follow-up—for patients with aortic disease.” Michael Belkin, MD, BWH Chief of Vascular Surgery, says, “Our combination of expertise, experience and investment in new technology allows us to manage all aspects of abdominal and thoracic aortic disease.”

Indications for referral

Center specialists provide care for patients with all manifestations of aortic disease, including ascending, arch, descending, and thoracoabdominal aortic aneurysms or dissections, abdominal aortic aneurysms, and aortic occlusive disease. Any patient who has symptoms of, or is at risk for, aortic disease, who has a family history of certain connective tissue diseases, such as Marfan Syndrome, or who has a history of bicuspid aortic valve (the most common cause of aortic valve pathology in patients under 70) may be referred to the Center for expert evaluation and management.

Surveillance

Patients with an identified aneurysm are monitored, usually with CT imaging, every three to six months, depending on the particular situation. A decision to intervene is based on the patient’s symptoms, the absolute size of the aneurysm, and the rate of enlargement. Most experts agree that aneurysms of the ascending aorta need to be treated at 5 cm, unless the patient has Marfan Syndrome. Marfan-related aneurysms tend to rupture at smaller sizes and are usually treated when they reach 4-4.5 cm. For aneurysms of the descending aorta, most experienced surgeons intervene when the lesion reaches 6 cm, or when the aneurysm enlarges more than 0.5 cm/year, and certainly for any evidence of leakage or impending or actual rupture.

Advanced Treatment Options

Surgeons and endovascular surgeons offer a full range of treatment options, tailored to the requirements of each patient. They offer complex surgical repair of all segments of the aorta. Advanced techniques for myocardial, cerebral, and spinal protection are used in these procedures to make them as safe as possible and reduce the risk of complications.

• Valve-sparing aortic root replacement. This procedure may be an appropriate option for patients who have aneurysms of the aortic root requiring aortic root replacement and having a competent aortic valve. The native aortic valve is saved and reimplanted in a tubular Dacron graft, sparing the patient the requirement of life-long anticoagulation associated with mechanical valves. This procedure is commonly offered for patients with Marfan Syndrome, and outcomes are excellent.
• Composite aortic root replacement. This technique involves a mechanical valve sewn into a tubular Dacron graft, and is indicated in patients with aneurysms of the aortic root associated with diseased aortic valves.
• Homograft aortic valve root replacement. A cryopreserved homograft valve and aortic root segment, recovered from a human cadaveric donor, may be used in reconstruction of complex valve and root pathology. It may be a good choice for patients with endocarditis with extensive native tissue destruction or patients who have had previous aortic root surgeries, because the graft resists recurrent infection and the patient avoids the need for long term anticoagulation.
• Surgery. All segments of the thoracic aorta can be replaced, alone or in combination, including the ascending aorta, the transverse aortic arch, the descending thoracic aorta, the thoracoabdominal aorta, and the abdominal aorta. State-of-the-art techniques for myocardial, cerebral, and spinal protection are used during these surgical procedures to make them as safe as possible for each patient;
• Endovascular thoracic aortic stent graft repair.
• Abdominal aortic disease. Minimally invasive, endovascular techniques are performed, as well as advanced open surgery for abdominal aortic aneurysms and occlusive disease.

“We are now applying our long standing experience with endovascular stent grafts for abdominal aortic aneurysms to aneurysms of thoracic aorta. In appropriate patients, these procedures allow us to replace complex open thoracic operations with minimally invasive endovascular procedures performed through the femoral vessels,” says Dr. Belkin.

This emerging technology has become more widely available and may offer some advantages for selected patients who may be at elevated risk for open surgery. The thoracic aortic stent graft team will include vascular surgeons and cardiac surgeons in order to offer the most appropriate treatment for each patient. Indications for endovascular repair will almost certainly expand significantly as new devices are proven safe and effective;

Expanded Research Initiative

Research efforts at the Center comprise basic, translational, and clinical studies to develop better ways of preventing complications of current procedures, safe and effective new devices and procedures, and less invasive techniques for treating aortic disease. Appropriately selected patients will continue to have the opportunity to participate in local and national clinical trials of new devices and treatments, including a multi-center trial comparing surgical repair and stent graft treatment for thoracic aortic dissection and traumatic injuries and trials for endovascular stent grafts to treat abdominal and thoracic aortic aneurysms. 

In addition, the Center is sponsoring a new initiative to add to the hospital’s existing cardiac surgery database additional data on aortic disease. Dr. Bolman says, “We will track and collect data regarding natural history, surveillance imaging, procedures (open as well as endovascular), outcomes, complications, and quality-of-life in order to gain a better understanding of aortic disease and develop safer and more effective therapies for our patients.”

Advanced Imaging

In addition to standard fluoroscopy and coronary angiography, patients of the Cardiovascular Center benefit from state-of-the-art imaging to provide precise diagnostic information and image-guided therapy, including:

• Cardiac MRA;
• CT imaging with 3-dimensional reconstructions.

The reconstruction allows the surgeon to focus on and manipulate the image of the aorta and visualize nearby critical structures, and is invaluable in surgical planning. Another reconstruction software program is used to specify the size, extent, and location of aneurysms and aid in stent graft placement;

• Transesophageal echocardiography (TEE). TEE is especially useful in diagnosing and managing aortic dissection;
• Intravascular ultrasound (IVUS). An ultrasound probe introduced into an artery provides valuable information concerning aortic pathology, including the thickness of the artery wall and the location of any injury or lesion;
• Aortic arteriography and percutaneous interventional therapy.